From 20-22 September 2010, world leaders will meet in New York City to discuss the United Nations’ “We Can End Poverty 2015” Millennium Development Goals, which include food security, maternal and child health, and environmental sustainability as key objectives, but controversially, make no mention of population. Officially, there is only one small “side session,” organized by Vicky Markham of the Center for Environment and Population, devoted to talking about the MDGs in the integrated context of population, health, and environment (PHE).

“If we could do something about unintended pregnancies – which are about 80 million a year – we could dramatically reduce population growth,” and reduce pressure on the environment, says Joseph Speidel in this short analysis from the Environmental Change and Security Program. Speidel discusses the connections between population, health, and environment issues, and offers solutions for the way forward.

The “Pop Audio” series offers brief clips from ECSP’s conversations with experts around the world, sharing analysis and promoting dialogue on population-related issues. Also available on iTunes.

“There is a knowledge gap between global targets and locally owned goals,” said Sallie Craig Huber, global lead for results management at Management Sciences for Health (MSH). The seventh meeting of the “Advancing Policy Dialogue on Maternal Health” series – cosponsored by the Global Health Council, MSH, and PATH – comes at a critical time as world leaders meet next week at the high-level, plenary UN Summit to review progress toward the Millennium Development Goals (MDGs).

Panelists Marge Koblinsky, senior technical advisor, John Snow Inc., Ellen Starbird, deputy director, U.S. Agency for International Development, and Monique Widyono, program officer of PATH, discussed strategies for improving maternal health evaluation methods while balancing the interests of donors and beneficiaries.

Maternal Health Indicators: Contact vs. Context

“Skilled birth attendants [have] become the strategy [for improving maternal mortality rates], but one size does not fit all,” said Koblinsky. The proportion of births attended by skilled birth attendants is a key maternal health indicator; however, it is not sufficient and says little about what the attendants actually did during the birth.

Koblinsky demonstrated how other indicators such as near-miss morbidity, rates of cesarean section, and contraceptive prevalence rates (CPR) are better aligned with maternal mortality outcomes. “CPR is much more closely linked with the outcome we desire as [contraception] reduces pregnancies for those at higher risk and reduces unwanted births and unsafe abortions,” said Koblinsky.

“Are the present benchmarks enough?” asked Koblinsky. “The answer is no….Indicators based on contact with skilled birth attendants focuses attention on contact, not on the quality of care or event context.”

Qualitative Data Is Necessary

“When we talk about monitoring and evaluation, transparency and accountability, it’s really critical to engage [in a discussion] on how we gauge progress,” said Widyono. In the field, “collection of data varies widely and depends on the capacity of those collecting, aggregating, and analyzing the information,” said Widyono. Such inconsistencies demand increased investment in local research capacity and qualitative analysis.

Such engagement also provides an opportunity for feedback. This “qualitative data helps to reinforce, illuminate, and deepen the understanding of what this quantitative data is showing on the ground,” said Widyono. Moving forward, policymakers, donors, and program managers will need to find a balance between these two sets of data and work together to galvanize action.

“There is a lack of attention paid to developing local, sustainable research capacity,” said Widyono. “We have an obligation to build local research capacity and disseminate findings in collaboration with the people who are going to be affected by this data,” she said.

Innovation and Research

“We really need to think about monitoring and evaluation and research and innovation as a continuum,” said Starbird. “They reinforce each other and play different roles in helping us understand what makes programs work or why they are not working.”

“We have a myriad of indicators that we expect people to monitor, collect data for, and report back to headquarters in a way that has not given countries and programs the freedom to be country-specific,” said Starbird. Therefore, “one of the goals is to minimize the reporting burden and better coordinate around indicator definition with other donors,” she said.

In order to strengthen “M&E;” for maternal health, Starbird called for new indicators as well as new ways of thinking about data analysis. “Having a results framework is really important to do good monitoring and evaluation,” she said. Evaluating the relationship between inputs, outputs, outcomes, and impacts requires a wide range of data resources so we can “get under the numbers” and determine what needs to be improved, she said.

“It’s really important to have realistic goals, otherwise it’s difficult to put programs into place and get where we want to go,” said Starbird. She said that MDG 5.B, which calls for universal access to reproductive health, “is great, but there’s never going to be universal access to reproductive health. If we really want to make progress we need to define something that is achievable and is something we can come together around.”

In conclusion, it is necessary to provide “countries with the room to do what needs to be done locally, so we can better understand these concepts rather than imposing indicators on everybody,” said Starbird.

Over the last three days, 700 technical experts have provided solutions to decrease maternal mortality. In the last year, governments have committed billions of dollars to implement such solutions. Yet, we’ve been here before, reminded Sigrun Mogedal of the Norwegian Ministry of Foreign Affairs during the final plenary session of the Global Maternal Health Conference. “Just look at ICPD, Beijing, and CEDAW. Obviously, there must be something wrong with accountability,” she said, since 15 years later women continue to die every minute giving birth.

Wrapping up the conference with a discussion of accountability makes sense – we need to learn from the past and close the gap between commitments made and real action on the ground. So what does today’s buzzword, “accountability,” mean, and how do we enforce the realization of commitments made…or lack thereof?

“Accountability is power, and includes transparency, answerability, and enforceability,” said Lynn Freedman of Columbia University. Through international law, budget transparency, and grassroots mobilization it is possible to ensure that policies make a difference to improve women’s lives.

A review of the Ministry of Finance’s allocation for health can tell us a lot about the government’s real commitment to eradicating maternal mortality. As the overarching instrument of policy the “budget is inextricably linked to development and exists for those who have less,” said Helena Hofbauer of the International Budget Project. “If there were greater transparency of government spending, we could have done more to push for change five years ago,” said Hofbauer. This is indeed true; however, it is also true that if governments simply followed through on the international agreements they are signatories to, women would be better protected.

Accountability through the legal system is possible and Nancy Northrup of the Center for Reproductive Rights demonstrated how international law has overhauled programs and sparked governments into action. For example, in India, the high court recently ruled that the government must execute audits and report back on the steps taken to align programs with policies that ensure a woman’s right to skilled birth attendance.

In order to bring about such judicial interventions a social movement must first be in place to build awareness and demand accountability. Building such a movement starts at the grassroots level and Aparajita Gogoi of CEDPA presented strategies for empowering local communities with a global voice. By providing a safe space for dialogue, communities are given the opportunity to share concerns and demand action from local health facilitators and government officials.

Increasing opportunities for dialogue allows for bottom up solutions and ensures that contextual variables are taken into consideration. “We need arenas for brokering diverse groups to compare notes and streamline synergies, ” said Mogedal. I am energized by the lessons learned today and eager to apply these key messages next week in Washington, DC during the seventh meeting of the Advancing Policy Dialogue for Maternal Health at the Woodrow Wilson International Center for Scholars that will further address “Monitoring, Transparency, and Accountability for Maternal Health.”

Originally posted on the Medscape blog Global Mamma, by Calyn Ostrowski of the Woodrow Wilson International Center for Scholars, Coordinator of the Maternal Health Dialogue Series in partnership with the Maternal Health Task Force and UNFPA.

Photo Credit: “Mothers and children waiting at the Bolemba healt centre” courtesy of flickr user hdptcar.

Four days ago a young woman died giving birth in a bustling marketplace in New Delhi. Just steps away from Parliament, this woman was left to die and no emergency care was sent to her – no midwives, nurses, or doctors; just people walking around her accepting the situation as normal and an uncontrollable way of life. But this is Delhi…not a remote tribal village where the nearest health clinic is hours away (on foot).

This juxtaposition lingers on in me as I sit in the plenary session of day two at the Global Maternal Health Conference and listen to Syeda Hameed, member of the Indian Parliament Planning Commission, discuss her recent visit to a remote village where every house has 10 children living in filth, flies, and emptiness.

Although I have been working on such development issues for the last five years I do not work in the field, nor do I visit the developing world on a regular basis. Hearing these stories, coupled with my firsthand experience of witnessing poverty here in Delhi reminds me of the daily reality of those 342,900 women who die every year. This is their way of life and I think it’s poignant that today’s sessions emphasize community based care, family planning, accountability, behavior change, and culture.

“Context, context, context,” said Wendy Graham of IMMPACT at yesterday’s plenary session. I agree, the context of social and cultural norms is an underlying factor that must be taken into consideration when implementing maternal and child health (MNCH) programs. With a background in psychology, I appreciated when Dr. Zulfiqar Bhutta, of Aga Khan University, recognized the toll of poverty on the imagination and the mentality of fatalism.

That is why it is so essential to “ask the people how they feel and bring their voices into the forums where policy decisions are made,” said Hameed. It is also important to hold key players accountable and include men in MNCH activities.

During the side session Male Involvement in Reproductive and Maternal and Newborn Health six field experts (in which half the panelists and audience members were men!) discussed effective methods for increasing male participation in family planning, vasectomies, gender equality, and hospital care.

The key findings from this discussion include:

• Targeted interventions that educate men about danger signs and pregnancy complications correlates with behavior change and increased facility births.
• Many young married men feel pressured to prove their fertility. A sample of men was evaluated and those who had increased education and income were more likely to delay first pregnancy.
• Vasectomy is not something men want to talk about with family planning fieldworkers; however, official recognition of the vasectomy benefits by the government did increase referrals.
• Puppet and theater shows that demonstrate gender equity behaviors provide an opportunity for dialogue. Women in this study reported increased gender equity in family planning decision-making.

There are so many variables that exacerbate the maternal mortality cycle, but evidence presented here provides REAL solutions. It is time to scale up these solutions and political willpower will be essential.

Originally posted at Maternal Health Task Force, by Calyn Ostrowski of the Woodrow Wilson International Center for Scholars, Coordinator of the Maternal Health Dialogue Series in partnership with the Maternal Health Task Force and UNFPA.

Photo Credit: “Parliament Street” courtesy of flickr user ~FreeBirD®~.

“We do not need new legislation… we need affordable, effective, and scalable solutions,” said Shn Gulamnabi Azad, Minister of Health, India, at the opening ceremony of the first-ever Global Maternal Health Conference in New Delhi. Co-hosted by the Maternal Health Task Force and the Public Health Institute of India, this three-day technical meeting builds upon the momentum of Women Deliver and the G8 summit by bringing together 700 researchers, program managers, advocates, media, and young people to exchange ideas, share data, develop strategies, and identify solutions for reducing maternal mortality.

In order to reduce India’s maternal mortality rates, Azad called for the repositioning of family planning programs to include maternal and child health and not limit the scope of services to population control as historically executed. Improving family planning and maternal health services must also address the reproductive health needs of adolescent girls, and India is currently developing a new ministry that will target gender inequality, poverty, early child marriages, as well as other critical health issues important to young girls such as the dissemination of sanitary napkins.

“Although the legal age of marriage is 18, there are districts in India where 35 percent of the population is married between the ages of 15-18,” said Azad. During the side event “Adolescent Girls: Change Agents for Healthy Mother and Child,” technical experts such as Anil Paranjap of the Indian Institute of Health Management presented evidence that girls who marry between 15-18 are five times more likely to die during childbirth than women in their early 20’s.

“We still have deep-rooted subordination that makes it very difficult for young women to realize their sexual and reproductive health rights,” said Sanam Anwar with the Oman Medical College. Interventions such as the UDAAN project – a private-public partnership between the Center for Development and Population Activities (CEDPA) and the Government of India – demonstrate promising solutions for empowering young people through the use of existing infrastructure. In collaboration with teachers, parents, principals, and students, this project successfully increased leadership skills and improved youth knowledge on menstruation, health, friendship, peer pressure, early marriage, and reproductive health, said Sudipta Mukhopadhyay of CEDPA.

Empowering “young people” to improve maternal health also requires that the community support committed new thinkers and future leaders. The Young Champions of Maternal Health Program is a unique and refreshing group of young professionals from 13 countries dedicated to improving maternal health, and I look forward to learning how this new energy will further the maternal health agenda.

Originally posted at Maternal Health Task Force, by Calyn Ostrowski of the Woodrow Wilson International Center for Scholars, Coordinator of the Maternal Health Dialogue Series in partnership with the Maternal Health Task Force and UNFPA.

Photo Credit: “Indian Girl” courtesy of flickr user Jarek Jarosz.

The 2010 Global Maternal Health Conference kicked off today, perhaps fittingly, in India – one of the world’s fastest growing nations but one that also faces serious reproductive health challenges. The Wilson Center’s Calyn Ostrowski is in New Delhi for the conference and will be providing updates to The New Security Beat throughout the week.

Those interested can also find a schedule of events and list of participants on the conference website as well as live webcasted events on the main page. Stay tuned!

Photo Credit: “Mumbai, India, November 2009” courtesy of flickr user travelmeasia.

In her recent post on The New Security Beat, Jennifer Sciubba argues that the medium-fertility variant projection published in the UN Population Division’s biennial projections — the source of most future data published in the Population Reference Bureau’s 2010 World Population Data Sheet — forecasts an unrealistically low total fertility rate (TFR) for sub-Saharan Africa in 2050, at a rate of 2.5 lifetime childbirths per woman.